ABDOMINAL TRAUMA

“SAHARA”
I. BLUNT ABDOMINAL TRAUMA
II. PENETRATING ABDOMINAL TRAUMA
• PERLU TIDAK DIOPERASI ? Kapan ?
• TOLERANSI PASIEN DALAM PEMERIKSAAN
DIAGNOSTIK
• MECHANISM OF INJURY
• TRAUMA SCORE Survival probality RTS
TINDAKAN SEGERA YANG DILAKUKAN SIMULTAN :
• Resusitasi
• Evaluasi
RESUSITASI
•ABCDE
• Chest X ray……TUBE THORACOSTOMY
• NGT
• URETHRAL MEATUS … blood
• Foley catheter
 EVALUASI BLUNT ABD TRAUMA

• Hypotensi cari penyebabnya

-cavum pleura
-cavum abdomen
-retroperitoneal
-extremitas
• Tanda tanda peritonitis --> Sulit ditentukan bila pasien :
- Trauma capitis
- Spinal cord injury
- Lower ribs fractures
- Pelvis fractures
- Abdominal wall contussions
• Jejas di abdomen (abrasions)
• Ecchymosis involving the flanks (Grey Turner sign) or the
umbilicus (Cullen sign) indicates retroperitoneal hemorrhage
Diagnostik prosedur BAT
• Chest X ray
• FAST (Focus abdominal sonogram for Trauma)
• Abd X ray - free air
- density
• IVP
• Retrograde cystography
• DPL
-20 cc darah atau isi usus –Tap
-Lavage 1000 cc salin , anak10-15 cc/ kg bb
RBC >100.000./mm3 , WBC >500/mm3
atau positif gram stain , isi usus

• CT Scans
Evaluasi Penetrating Abd Trauma
Lebih mudah dari pasien dengan BAT
• Hypotensi
• Abd distension
• Peritonitis
• Prolaps omentum , usus
• Sign visceral hemorrhage
- Hematemesis
- Proctorrhagia
- Hematurie
Diagnostic prosedur PAT
• Chest X Ray
• Abd X Ray : -free air
-Traumatic Diaph.hernia
-peluru di peritoneal cavity
• Gross hematurie……IVP
• Observasi: - No Shock
- No signs of peritonitis
- No evisceration
• DPL : -penetrating di pinggang dan
posterior abdomen
Stab Wounds
• Anterior Abdomen
- Explorasi luka  sikap tembus peritoneum
- Laparotomi
- Observasi

• Posterior abdomen
- DPL ?  colon Asc,Desc
pancreas/doudenum,ginjal
- Observasi
- CT contrast , ngt, enema , iv
Gunshot Wounds
• Anterior Abdomen
- Automatic laparotomy
• Posterior Abdomen
- Observasi
- DPL
- CT scan contrast
• Senapan angin
- Foto lateral abdomen
- laporotomy
- observasi
General operative approach
• Skin preparation and incisions
• Prevent Hypothermia
• Conduct of operation :
- Hemodinamic status
- Siap darah
- Auto transfusi
- Stop segera sumber perdarahan
- Tutup sementara sumber perforasi
- Explorasi sistimatis
- Follow the track
• Cegah menjadi Sepsis (antibiotics ,aseptic & antiseptic)
Blunt Abdominal trauma
The most commonly injured organs are
• Spleen
• Liver
• Retroperitoneum
• Small bowel,
• Kidneys,
• Bladder,
• Colorectum,
• Diaphragm
• Pancreas
Treatment Liver Trauma

• Nonoperative Observasi dengan CT scan

- Hemodinamic stabil
- Peritonitis Sign (-)

• Operative
 Segmental anatomy of the liver
• Left Lobe
1. Lateral superior
2. Lateral inferior
3. Medial superior
4. Medial inferior
• Right Lobe
1. Anterior Superior
2. Anterior Inferior
3. Posterior Superior
4. Posterior Inferior
 Yang perlu diperhatikan

• Biliary drainage
• Arterial blood supply
• Portal circulation
• Venous blood supply
• Lymphatics drainage
• Vena cava Inferior
Liver injury scale
• Grade I.Hematoma SC < 10 %,laserasi <1cm
parerenchymal depth
• Grade II. Hematoma SC 10-50%,laserasi 1-3 cm
parenchymal depth
• Grade III.HSC >hematom 50%,laserasi > 3 cm
parenchymal depth
• Grade IV.Parenchymal disruption 25 – 50 % of
hepatic lobe
• Grade V.Parenchymal disruption> 50 %hepatic
lobe
• Grade VI.Vasculer Hepatic avulsion
Tehnik Repair Liver trauma
• Suture Hepatorrhapy
• Peri Hepatic packing
• Omental pack
• Pringle maneuver
• Resectional debridement
• Selective vascular ligation
Penyulit/komplikasi
• Hemmorrhage / Hemobilia

• Intra abdominal abscess

• Hyperpyrexia

• Biliary fistula
Gallbladder and EHB
• Gallbladder
- Pasien stabil --> cholecystectomy
- Tidak stabil - tube cholecystostomy
 cholecystorrhapy
• EHB
- Absorbable suture Stenting T tube
- Chledochoyeyunostomy
- Cholecystoyeyunostomy
- Whipple prosedur
LIMPA
• FUNGSI :
1. Pembentukan darah

2. Phagocytosis

3. Pembentukan anti bodi

4. Immuosuppresor system
TREATMENT
• Non operative dng CT scans observasi
1. Hemodinamik stabil
2. Tanda peritonitis (-)
3. Transfusi tidak lebih 2 unit darah

• Operative
1. Splenorrhapy
2. Splenectomy
Shackford Grade

• Grade I.capsular tear , minor parenchymal

lacerasi
• Grade II.minor capsular avulsion
• Grade III. Major parenchymal laserasi
• Grade IV. Severe parenchymal stellate
fracture, hillar injury
• Grade V. Spleen avulsi
Gaster

• Gastorrhapy

• Occult Gastric perforation

• Resection
DOUDENUM
• Sulit dalam mendiagnosa karena :
- Retroperitoneal
- Jumlah bakteri
- Ph netral .. No chemical peritonitis
• Abdominal X ray:
- air bubble didepan Th. L 1 (Lateral foto)
- hilangnya gambaran garis Psoas
- scoliosis lumbar spine
- retroperitoneal air
• Mekanisme cedera perhatikan
• Hyperamylasemia
Diaknostik

• Abdominal X Ray

• CT scan contras
Exposure Duodenum

• Kocher maneuver

• Extended Kocher maneuver

Maneuvre extra peritoneal

• Kocher Maneuver
• Extended Kocher maneuver
• Extensive retoperitoneal exposure
(Cattle –Braasch maneuver)
• Left sided medial visceral rotation
(Mattox maneuver )
Kocher Maneuver
Extended Kocher maneuver
Extensive retoperitoneal exposure
(Cattle –Braasch maneuver)
Left sided medial visceral rotation
(Mattox maneuver )
Treatment
• Non surgical
- Intramural hematom

• Surgical
- Simple closure
- Rouex-en-Y doudenojejunostomy
- Triple tube
- Whipple prosedur
Penyulit/Komplikasi pasca bedah
• Duodenal fistula
- Conservative
- Reoperation
Retrocolic Roux-en-Y loop to site
duodenal fistula
PANCREAS
• Exposure
- Anterior via gastrocolic omentum
- Posterior via Kocher maneuver
• Treatment
- Drainage
- Pancreatorrhapy + Drainage
- Distal pancreatectomy + Roux-en-Y
- Proximal pancreatoduodenectomy
Pembagian Zona
Retroperitoneal
 Approach to Traumatic Retroperitoneal
Hematoma

Type-Hematoma Penetrating Injury Blunt Injury

Central (Zone I) Explore Explore

Lateral (Zone II) Usually explore Usually do not explore
Pelvic (Zone III) Explore Do not explore
 RETRO PERITONEAL HEMATOM
Location BTA PAT
I. Midline
-SMC Open* Open*
-IMC Open* Open*
II. Lateral
-Perirenal IVP ? Open*
-Pelvic Open(-) Open*
Pulsasi arteri
III. Portal Open* Open*
*After proximal vascular control
 Hematoma Retroperitoneal

• Persoalan utama : Apakah perlu

eksplorasi atau observasi saja ?

• Peraturan umum : Pada trauma tembus,

semua hematoma retroperitoneal harus
dieksplorasi, tidak tergantung kepada
lokasi dan besarnya hematoma
Small Instestine

• Simple closure

• Resection
colon
Diagnostic :
• Abd X ray
• DPL
• CT scan contras
• Observasi
 Colon injury
A. Level I
There is sufficient class I and class II data to support a standard of
primary repair for nondestructive colon wounds in the absence
of peritonitis.
B. Level II
• 1. Patients with penetrating intraperitoneal colon wounds which are
destructive can undergo resection and primary anastomosis
if they are:
… Hemodynamically stable without evidence of shock,
… Have no significant underlying disease,
… Have minimal associated injuries,
… Have no peritonitis.
• 2. Patients with shock, underlying disease, significant associated injuries,
destructive colon wounds managed by
or peritonitis should have
resection and colostomy.
 Colon injury

• 3. Colostomies performed following colon and rectal

trauma can be closed within two weeks if contrast
enema is performed to confirm distal colon healing. This
recommendation pertains to patients who do not have
non-healing bowel injury, unresolved wound sepsis, or
are unstable.
• 4. A barium enema should not be performed to rule out
colon cancer or polyps prior to colostomy closure for
trauma in patients who otherwise have no indications for
being at risk for colon cancer and or polyps.
RECTAL INJURY
1. Intraperitoneal wounds
2. Extraperitoneal wounds

Diagnostic :
• Proctoscopy
• Sigmoidoscopy
 Treatment Rectal Injury
• Multiple antibiotics
• Intraperitoeal
- Laparotomi
- Rectal injuries above the peritoneal reflection can be treated
as colonic injuries and repaired primarily.
• Extraperitoneal
- Rectal injuries should be repaired primarily if possible.
The rectum can be mobilised to allow repair, and posterior wall
injuries repaired through an anterior wound or colotomy. (Do not
repair an anterior wound without examining the posterior rectal
wall).
- Low rectal injuries can be repaired trans-anally 
Debridement + Proximal colostomy
TRAUMA SCORES AND SCORING SYSTEMS

In principle, scoring systems can be divided

into:
• Physiological Scoring Systems.
• Anatomical Scoring Systems.
• Outcome Analysis Systems.
PHYSIOLOGICAL SCORING SYSTEMS

• Glasgow Coma Scale

• Revised Trauma Score

 The Glasgow coma scale.
Parameter Response Score
Nil 1
To pain 2
Eye opening
To speech 3
Spontaneously 4
Nil 1
Extensor 2

Motor response Flexor 3

Withdrawal 4
Localising 5
Obeys command 6
Nil 1
Groans 2

Verbal response Words 3

Confused 4
Orientated 5
 Revised Trauma Score (RTS)
Clinical Parameter Category Score X weight

10-29 4
>29 3
Respiratory rate 0.2908
(Breaths per minute) 6-9 2
1-5 1
0 0
>89 4
76-89 3
Systolic blood 0.7326
Pressure 50-75 2
1-49 1
0 0
13-15 4
9-12 3
Glasgow Coma 0.9368
Scale 6-8 2
4-5 1
3 0
 Systolic
Glasgow Respirat
Blood Coded
Coma Scale ory Rate
Pressure Value
(GCS) (RR)
(SBP)
13-15 >89 10-29 4
9-12 76-89 >29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0

RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR

Values of the RTS 0 – 7.84